Provider Demographics
NPI:1205514379
Name:KEODALAH, VICTOR
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:
Last Name:KEODALAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9636 50TH AVE S
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98118-5439
Mailing Address - Country:US
Mailing Address - Phone:206-852-0911
Mailing Address - Fax:
Practice Address - Street 1:651 STRANDER BLVD STE 105
Practice Address - Street 2:
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98188-2914
Practice Address - Country:US
Practice Address - Phone:206-852-0911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-10
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACB61433009106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician